Visual Acuity

Separately test each eye (wearing glasses or contacts, if any) using a Snellen chart at 20 feet. Alternatively, use a near vision card at 12 or 14 inches, and document acuity. If the patient is unable to read any lines, document perception to counting fingers; if unable, then perception to hand motions; or if still unable, then perception to light. Repeat test with pinhole occlusion of each eye separately and record visual acuity. If no pinhole occlusion device is available, poke a small hole in a business card and use this.

Loss of visual acuity: Cataracts, glaucoma, retinal vessel occlusion, retinal detachment, temporal arteritis, meds (e.g., rifabutin, hydroxychloroquine), papilledema, optic neuritis (e.g., MS), CVA, additional diagnosis.

Visual Field by Confrontation

Test each eye separately by holding fingers up in 4separate quadrants equidistant from the patient and examiner.  Ask the patient to report the number of fingers seen using the your normal visual field as a baseline. The patient should be staring into your eye that is directly opposite to him or her throughout the test.

Loss of visual acuity: Cataracts, glaucoma, retinal vessel occlusion, retinal detachment, temporal arteritis, meds (e.g., rifabutin, hydroxychloroquine), papilledema, optic neuritis (e.g., MS), CVA, additional diagnosis.

Intraocular Pressure (IOP)

Do this unless there is suspicion of a ruptured globe. Administer the anesthetic proparacaine 0.5% (1 drop to each eye), and then use a tonometer to record each eye’s pressure (normal 10-21 mm Hg).

Causes of elevated IOP: Glaucoma, orbital compartment syndrome.

Penlight Exam

Pupils: Document size, reactivity to light, symmetry, and presence of any paradoxical dilation to light (by swinging flashlight test). 

Anterior chamber: Estimate depth between cornea and iris by side illumination of the iris. A deep anterior chamber (safe to dilate eyes) has a completely illuminated iris, whereas a shallow anterior chamber (do not dilate eyes) has only partial illumination.

Loss of visual acuity: Cataracts, glaucoma, retinal vessel occlusion, retinal detachment, temporal arteritis, meds (e.g., rifabutin, hydroxychloroquine), papilledema, optic neuritis (e.g., MS), CVA, additional diagnosis.

Extraocular Movement (EOM)

Ask patient to follow your finger up, down, left, and right without head movement. Observe the patient for any limitations, smoothness of movements, and symmetry. Palpate the orbital rim for step-offs/tenderness.

Abnormal EOM: Strabismus (from trauma, thyroid disease, sensory deprivation), orbital fracture. 

Direct Observation

Note the presence or absence of proptosis. Evaluate each lid, conjunctiva, episclera, sclera, cornea, anterior chamber, iris, and pupil. Check for patterns of redness, presence of conjunctival discharge or ulcers, or anterior chamber hypopyon or hyphema (collection of white or red cells, respectively, usually at the 6o’clock position of the iris).

Trauma, hyperthyroid, orbital cellulitis, infection, foreign body, inflammation (autoimmune), chemical burn, conjunctival hemorrhage.

Direct Ophthalmology

A normal exam should include a bright red reflex that is uniform at all angles and symmetrical, flat and well-demarcated optic disc margins, uniform and normal caliber arteries and veins, and a clear image of the retina without hemorrhage, bright yellow exudate, or ischemic pale-yellow cotton-wool spots. If the anterior chamber appears deep by penlight exam, use tropicamide 1% and phenylephrine 2.5% for dilation to facilitate the exam.

Cataracts, glaucoma, retinopathy (DM, HTN, sickle cell), retinal detachment, retinitis, choroiditis, vasculitis.

Flourescein Staining

Administer fluorescein, then observe under cobalt blue light on the direct ophthalmoscope. Any disruption in corneal epithelium will fluoresce bright green

Abnormal fluorescein: Trauma, prolonged exposure or drying.

Amsler Grid Testing

Have the patient hold an Amsler grid at a normal reading distance and wearing corrective lenses, if any. Using one eye at a time, have patient stare at the central dot and document any distortions or blind spots directly on the grid. Printable grid: www.stlukeseye.com/EyeQ/AmslerPrint.html (accessed 5/2/13)

Abnormal amsler grid testing: Macular degeneration, optic nerve lesions.